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
Ci a ion: Lou ei o, A.; Pa idá io,
M.d.R.; San ana, P. S a egic
Assessmen o Neighbou hood
En i onmen al Impac s on Men al
Heal h in he Lisbon Region
(Po ugal): A S a egic Focus and
Assessmen F amewo k a he Local
Le el. Sus ainabili y 2022,14, 1547.
h ps://doi.o g/10.3390/su14031547
Academic Edi o : Gideon Ba oe
Recei ed: 12 No embe 2021
Accep ed: 20 Janua y 2022
Published: 28 Janua y 2022
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sus ainabili y
A icle
S a egic Assessmen o Neighbou hood En i onmen al
Impac s on Men al Heal h in he Lisbon Region (Po ugal): A
S a egic Focus and Assessmen F amewo k a he Local Le el
Ad iana Lou ei o 1,* , Ma ia do Rosá io Pa idá io 2and Paula San ana 1
1
Cen e o S udies in Geog aphy and Spa ial Planning (CEGOT) and Depa men o Geog aphy and Tou ism,
Uni e si y o Coimb a, Colégio de São Je ónimo, 3004-530 Coimb a, Po ugal; [email p o ec ed]
2Cen e o Inno a ion in Te i o y, U banism and A chi ec u e o IST (CiTUA-IST) and Depa men o Ci il
Enginee ing, Ins i u o Supe io Técnico (IST), Uni e sidade de Lisboa, A enida Ro isco Pais, 1,
1049-001 Lisbon, Po ugal; [email p o ec ed]
*Co espondence: [email p o ec ed]
Abs ac :
Scien i ic e idence shows ha each place/en i onmen gene a es speci ic condi ions wi h
associa ed impac s on he men al heal h and well-being o he popula ion. A holis ic, mul ile el and
in eg a ed en i onmen al app oach o men al heal h enhances he unde s anding o his phenomena,
suppo ing he local decision-making p ocesses o imp o e spa ial planning o neighbou hood
en i onmen s. The aim o his s udy is o de elop a s a egic assessmen amewo k, based on
ou municipali ies in he Lisbon Region (Po ugal), ha explo es policy and planning ini ia i es
capable o gene a ing a ou able neighbou hood en i onmen al condi ions o men al heal h while
also de ec ing isks. Using baseline esul s o signi ican s a is ical associa ions be ween indi iduals’
pe cep ions o hei neighbou hood en i onmen and hei men al heal h in he Lisbon Region, a
S a egic Focus on En i onmen al and Men al Heal h Assessmen amewo k (SEmHA) was buil ,
by applying he me hodology “S a egic Thinking o Sus ainabili y” in S a egic En i onmen al
Assessmen , de eloped by Pa idá io in 2012. Taking in o accoun he p omo ion o he popula ion’s
men al heal h, ou c i ical decision ac o s o neighbou hood en i onmen s we e iden i ied: (1) public
space quali y (e.g., imp o ing sense o place), (2) physical en i onmen quali y (e.g., low le els o
noise exposu e), (3) p o essional quali ica ion and c ea ion o economic ac i i ies (e.g., a ac ing new
economic ac i i ies), and (4) se ices and acili ies (e.g., imp o ing access o heal h and educa ion
se ices). The p oposed s a egic ocus and assessmen amewo k con ibu es o ensu ing ha
in e en ions in neighbou hood en i onmen s uly achie e communi y men al heal h bene i s and
educe inequali ies, hus helping policy make s o assess impac s a he local le el.
Keywo ds:
in eg a ed assessmen ; s a egic en i onmen al assessmen ; heal h impac assessmen ;
men al heal h; neighbou hood en i onmen ; Lisbon egion
1. In oduc ion
Men al heal h is an inhe en componen o people’s o e all heal h and wellbeing
[1,2]
.
A pe son’s men al heal h is dependen on hei indi idual cha ac e is ics and li e expe-
iences, as well as being in luenced by he places and en i onmen s ha suppo hei
li es yles and ac i i ies, e.g., esidence, wo k o s udy places, ec ea ional, leisu e and mo-
bili y acili ies, e c. [
3
–
6
]. In ecen yea s, e idence has been collec ed on holis ic, mul ile el
and in eg a ed en i onmen al app oaches o men al heal h [
7
,
8
], pa icula ly as a esul
o he cu en COVID-19 pandemic [
9
–
12
]. Such knowledge suppo s he ac ha each
place (e.g., neighbou hood), h ough a complex in e ela ion o mul iple ac o s, gene a es
speci ic condi ions which impac he men al heal h and well-being o he popula ion [
13
,
14
].
I is possible ha neighbou hood en i onmen s exe an in luence on indi idual men al
heal h h ough isk educ ion, o example, by modi ying an indi idual’s beha iou wi h
Sus ainabili y 2022,14, 1547. h ps://doi.o g/10.3390/su14031547 h ps://www.mdpi.com/jou nal/sus ainabili y
Sus ainabili y 2022,14, 1547 2 o 27
espec o physical ac i i y [
15
–
17
] o h ough an emo ional bond o place (place a ach-
men ) [
18
,
19
]. Consequen ly, he na u al, buil and social neighbou hood en i onmen s can
ei he encou age o discou age indi idual cycling o walking. This e ec on beha iou s
sugges s ha policies, plans, p og ams, and hei assessmen can ha e a signi ican im-
pac on men al heal h de e minan s by gene a ing ac ions and c ea ing o changing he
condi ions ha in luence men al heal h [20,21].
Planning heal hie places, capable o p omo ing he heal h and well-being o hei
inhabi an s, is one o oday’s g ea es challenges, ecognized by he Te i o ial Agenda
2030 [
22
]. This is pa icula ly impo an o local in e en ions in neighbou hood en i on-
men s. U ban planning p ocesses mus be based on knowledge abou he en i onmen al
cha ac e is ics ha ha e po en ial e ec s on heal h and human well-being, and he ela ion-
ships be ween hem [
14
,
23
]. To ope a ionalize he concep o a “heal hy place”, app op ia e
a iables, me hodologies, and ins umen s mus be in eg a ed in o hese p ocesses [24].
Impac assessmen me hodologies, in pa icula Heal h Impac Assessmen (HIA)
and S a egic En i onmen al Assessmen (SEA), unde aken oge he wi h in eg a i e
and sus ainabili y-o ien ed app oaches [
25
–
29
], a e pa icula ly ele an o add essing he
in luence o spa ial planning on men al heal h de e minan s. These ins umen s aim o
assess he po en ial impac s and e ec s, o , mo e s a egically, he isks and oppo uni ies o
de elopmen op ions, policies, plans, p og ams, o p ojec s o men al heal h, s a ing om
he poin o iew o heal h de e minan s (including he cha ac e is ics o he neighbou hood
en i onmen ) and suppo ing decision-making p ocesses downs eam [30–33].
In he las decade, he conce n o men al heal h wi hin HIA p ocesses has g own,
al hough ep esen a ion o his opic is no ye sa is ac o y [
34
,
35
]. A sys ema ic e iew,
conduc ed in he Uni ed S a es, ega ding he in eg a ion o men al heal h in o HIA [
35
]
obse ed ha 73% o he HIA analysed included men al heal h (114 in 156). Howe e , only
38% o hese HIA measu ed baseline men al heal h condi ions, highligh ing ha men al
heal h is no epo ed on, o ollowed up, a all phases o he HIA [35].
Fo he pu pose o p omo ing and p o ec ing indi idual and communi y men al heal h,
assessmen app oaches combining en i onmen al and men al heal h ac o s should ocus
on he implica ions o men al heal h o s a egies, in e en ions, and poli ical decisions [
36
].
The in eg a ed analysis o indi idual, communi y, and en i onmen , enhances he s a egic
unde s anding o men al heal h phenomena, and suppo s he imp o ed spa ial planning
o neighbou hoods in local decision-making p ocesses. Such s a egic analysis enables an
assessmen o planning ac ions in ela ion o he isks and oppo uni ies o he men al
heal h and well-being o he communi y [
14
,
37
]. I is he e o e undamen al o include he
assessmen o men al heal h condi ions when de eloping sus ainable ac ions which a e
place- and people-o ien ed [24].
Such s a egic and in eg a ed assessmen s should be d i en by guiding ac o s in-
cluding, bu no limi ed o: (i) unde s anding he men al heal h con ex ual condi ions
in an in eg a ed way (e.g., biophysical, beha iou al, social, ins i u ional and economic
condi ions); (ii) analysing he oppo uni ies and isks o de elopmen op ions, mo i a ed
by he need o ans o m p oblems in o bene i s; (iii) inc easing he oppo uni ies a o ded
by he neighbou hood en i onmen o make heal hy choices, by ein o cing he con ol, e-
silience and s eng hs o he communi y and hei heal h, (i ) acili a ing he pa icipa ion o
indi iduals as c ucial ac o s, and ( i) p omo ing inclusion in he communi y [21,27,38,39].
Since he mid-20 h cen u y, impac assessmen ins umen s (e.g., En i onmen al Im-
pac Assessmen —EIA and HIA, and la e SEA) eme ged as oppo uni ies o he applica-
ion o in e sec o al ac ion in heal h [
40
–
42
]. This is based on he e idence ha in e en ions
and policies ou side he exclusi e domain o he heal h sec o ha e epe cussions on heal h
and heal h equi y [
42
–
44
]. This unde s anding ul ima ely led o he ini ia i e “Heal h in All
Policies” [
45
–
47
]. Mo eo e , HIA ools a e equi y- ocused and in luenced by he concep s
o social jus ice and spa ial jus ice [
39
,
48
]. These esea ch app oaches and ins umen s a e
c ucial o suppo ing knowledge and imp o ing esponses du ing pe iods o c isis such as
he cu en COVID-19 pandemic [49–53].
Sus ainabili y 2022,14, 1547 3 o 27
In Po ugal, esea ch on he impac s o en i onmen al ac o s on men al heal h s a ed
wo decades ago, d i en by esea ch p ojec s such as Heal h Impac Assessmen (HIA)
in Employmen S a egies (2009–2014), SMAILE (2013–2015), and Men al Heal h-C isis
Impac (2015–2017). These p ojec s gene a ed insigh s abou he local and economic ac o s
ega ding men al heal h in he con ex o c isis [
54
–
60
], pa icula ly impo an and use ul
e idence o suppo esea ch and men al heal h impac assessmen du ing he COVID-19
heal h c isis [61,62].
In ligh o he abo e, his s udy in ends o con ibu e o he scien i ic knowledge by
asking wha neighbou hood en i onmen de elopmen s a egies bes p omo e men al
heal h a he local le el. Thus, i s aim is o de elop a S a egic Focus on En i onmen al
and Men al Heal h Assessmen (SEmHA) amewo k. This amewo k will look a policy
and planning ini ia i es capable o gene a ing a ou able condi ions o men al heal h,
and a he same ime, de ec he cons aining condi ions ha can gene a e isks o men al
heal h. In o de o assess local planning s a egies, a me hodology o es ablish a s a egic
ocus on en i onmen al neighbou hood condi ions ha a e associa ed wi h men al heal h
was de eloped. The idea o he SEmHA builds upon he me hodological amewo k
o “S a egic Thinking o Sus ainabili y” in a SEA ( i s s age—con ex and s a egic
ocus) de eloped by Pa idá io [
27
]. The esea ch was ca ied ou in ou municipali ies
in he Lisbon Region (Po ugal), a e a pe iod o economic c isis, by conduc ing, i s ly,
a su ey o analyse he impac o neighbou hood en i onmen s on he men al heal h o
he popula ion. Secondly, esul s om he su ey suppo ed he design o he SEmHA
amewo k. Conclusions a e d awn on he ad an ages o he SEmHA o he p omo ion o
popula ion men al heal h and heal h equi y.
2. Ma e ials and Me hods
2.1. S udy A ea
The s udy a ea consis s o he municipali ies o Amado a, Lisbon, Ma a, and Oei as,
which we e selec ed om he Region o Lisbon (G ea e Lisbon, NUT III—2002) (
Figu e 1
).
These a eas ep esen consolida ed u ban a eas (Lisbon), ecen u ban g ow h a eas (Amado a,
Oei as), and u al a eas (Ma a), acco ding o hei dis inc geog aphical and socioeconomic
cha ac e is ics p esen ed in Table 1. Lisbon displayed high popula ion densi y (2020); how-
e e , he municipali y los popula ion be ween 1991 and 2011. Amado a and Oei as showed
high alues o inhabi an s pe km
2
, bu wi h opposi e p o iles, Amado a being he munici-
pali y wi h he highes alues ega ding popula ion a ia ion, numbe o o eign na ionals,
dep i a ion, unemploymen , o e c owding numbe o school lea e s, and also he lowes
educa ional a ainmen . The lowes popula ion densi y was obse ed in Ma a.
Table 1. Geog aphical and socioeconomic cha ac e is ics o he s udy a ea by municipali ies.
Lisbon Amado a Oei as Ma a
Popula ion densi y (inhab./km2) 2020 5093.4 7799.8 3875.0 292.5
Popula ion a ia ion (%) 1991–2011 −17.5 −3.8 13.7 75.4
Popula ion unde 15 yea s old (%) 2020 16.9 15.8 15.1 16.1
Elde ly li ing alone (%) 2011 15.0 10.8 10.6 7.8
Popula ion o o eign na ionali y (%) 2011 5.8 10.2 5.4 4.8
Unemploymen a e (%) 2011 11.8 15.0 10.8 9.1
School lea e s a e (%) 2011 1.8 2.7 1.2 1.4
Popula ion wi h highe educa ion (%) 2011 33.6 16.3 33.4 17.4
O e c owded li ing qua e s (%) 2011 12.1 17.7 11.4 9.9
Popula ion li ing in small a eas wi h high
ma e ial dep i a ion (%) 2001 [63]9.6 19.34 0.0 9.4
Sus ainabili y 2022,14, 1547 4 o 27
Figu e 1.
Loca ion o he s udy a ea: he ou municipali ies), Amado a, Lisbon, Ma a, and Oei as,
om he Region o Lisbon (G ea e Lisbon, NUT III—2002).
2.2. Da a Collec ion
In o de o c ea e a baseline o en i onmen al neighbou hood condi ions associa ed
wi h indi iduals’ men al heal h, a su ey was ca ied ou be ween Augus 2014 and Feb u-
a y 2015, a ge ing he popula ion aged 18 and olde li ing in he ou municipali ies. The
s a is ical popula ion consis s o 808,110 inhabi an s [
64
], o which da a om 1066 esiden s
was collec ed, h ough a ep esen a i e andom sample (by quo a acco ding o sex and
age by municipali y), wi h a ma gin o e o o 6% and a con idence le el o 95%. The
in e iews ook place on he s ee , andomly and in-pe son, by ained in e iewe s.
The su ey collec ed indi idual in o ma ion on sel -assessed men al heal h s a us and
on he pe cep ion o neighbou hood en i onmen al cha ac e is ics (Table 2): (i) physical
and buil en i onmen (sa is ac ion wi h heal h, spo s, educa ional, cul u al, public ans-
po , associa i e/communi y, ou doo leisu e, and local comme ce acili ies and se ices;
sa e y; u ban cleaning; noise; ai quali y; use o g een spaces; anspo used o commu -
ing), (ii) socioeconomic en i onmen (educa ion, p o essional s a us; ype o p o ession;
ma i al s a us; household inancial si ua ion; household income; unemploymen in he
amily; household budge mos ly alloca ed o heal h, educa ion, o housing), and (iii)
social and cul u al in e ac ion en i onmen (sense o belonging and iden i y; amily and
communi y ela ional suppo ; isola ion; us in public ins i u ions). These neighbou hood
en i onmen al a iables we e included in he su ey because he e is scien i ic e idence
o hei associa ion wi h men al heal h (p esen ed in Table 2). Table 3p esen s he gene al
cha ac e is ics o he sample.
Sus ainabili y 2022,14, 1547 5 o 27
Table 2. Va iables o neighbou hood en i onmen al cha ac e is ics p esen in he su ey.
Neighbou hood En i onmen al Cha ac e is ics and Scien i ic Li e a u e Re e ences
(Associa ion wi h Men al Heal h) Su ey Ca ego ies
Physical and buil
en i onmen
Sa is ac ion wi h esidence a ea
[65–72]
Heal h acili ies and se ices No sa is ied; Sa is ied
Educa ional acili ies and
se ices No sa is ied; Sa is ied
Spo s acili ies and se ices No sa is ied; Sa is ied
Cul u al acili ies and se ices
No sa is ied; Sa is ied
Associa i e and communi y
acili ies (e.g., associa ions,
ec ea ion cen es, clubs)
No sa is ied; Sa is ied
Public anspo acili ies and
se ices No sa is ied; Sa is ied
Pa king No sa is ied; Sa is ied
Ou doo leisu e acili ies and
se ices No sa is ied; Sa is ied
Local comme ce No sa is ied; Sa is ied
Sa e y No sa is ied; Sa is ied
En i onmen al Quali y
[73,74]
Indoo noise le els (a home) No sa is ied; Sa is ied
Ou doo noise le els No sa is ied; Sa is ied
Ou doo ai quali y No sa is ied; Sa is ied
U ban cleanliness (e.g.,
ga bage collec ion) No sa is ied; Sa is ied
Mobili y and T anspo s
[75–78]
Type o anspo used o
commu ing Mo o ized; non-mo o ized
P i a e mo o ized; No
mo o ized o public
A e age a el ime o daily
commu ing <20 min; ≥20 min
G een Spaces [17,79]
Use Yes; No
P oximi y o esidence
Use o he nea es g een space;
No using he nea es g een
space
F equency o use
Mon hly o less; Weekly; Daily
Use ulness o he exis ence
nea he esidence Yes; No
Socioeconomic
en i onmen
Educa ion [80,81]≤12 yea s; >12 yea s
Labou [82–88]
P o essional s a us Unemployed; Employed;
S uden ; Re i ed; Homemake
Type o p o ession
Manual wo ke ; Non manual
wo ke ; Unquali ied manual
wo ke
Unemploymen in he las
h ee yea s Yes; No
Unemployed in he amily Yes; No
Sa is ac ion wi h he job o e
in he a ea o esidence No sa is ied; Sa is ied

Sus ainabili y 2022,14, 1547 6 o 27
Table 2. Con .
Neighbou hood En i onmen al Cha ac e is ics and Scien i ic Li e a u e Re e ences
(Associa ion wi h Men al Heal h) Su ey Ca ego ies
Ma i al s a us
[89,90]
Single; Ma ied; Di o ced;
Widow(e )
Household and su ounding
inancial si ua ion [91–95]
Di icul y in paying expenses
Di icul y in paying expenses;
Able o pay cu en expenses
only; Able o sa e money
Conce n abou expenses
Mo e conce ned wi h
expenses; Less conce ned wi h
expenses
Main expense o
hehousehold budge
Heal h expenses; Educa ion
expenses; Housing expenses
Family membe , iend,
neighbou wi h di icul y
paying expenses
Yes; No
Household income
[96–100]≤500 €; >500 €
Dependen pe sons
[101]
Dependen child en; O he
dependen s; No dependen s
Social and cul u al
in e ac ion en i onmen
Sense o belonging and iden i y
[102,103]
Like li ing in he
neighbou hood Like; Dislike
Residence ime in he
neighbou hood ≤5 yea s; >5 yea s
Family and communi y ela ional
suppo
[102,104–108]
Rela ionship wi h neighbou s Bad/wi hou ela ion; Good
ela ion
Financial suppo
Neighbou s; Family and
F iends; Bank; Social
Solida i y Ins i u ions;
Nobody
Emo ional suppo
Neighbou s; Family and
F iends; Heal h P o essionals;
Social Solida i y Ins i u ions;
Nobody
Isola ion [109] Li ing alone Yes; No
T us in public ins i u ions
[110,111]
Vo ing in he las municipal
elec ions Yes; No
Vo ing in he las
pa liamen a y elec ions Yes; No
2.3. Measu e o Men al Heal h
Sel -assessed men al heal h s a us was measu ed by he men al heal h and i ali y
scale o he Sho Fo m 36-i em Heal h Su ey (SF-36 2), alida ed o he Po uguese
popula ion [
112
]. The SF-36 2 is used o assess heal h- ela ed quali y o li e [
113
]. The
men al heal h and i ali y scale anges om 0 o 100, co esponding o si ua ions in which
he indi idual expe iences o al disabili y, and no disabili y, espec i ely. This scale was
compu ed ollowing he me hodology p oposed by Wa e e al. [
114
], whe e sco es lowe
o equal o 50 ep esen poo men al heal h and sco es highe han 50 indica e good
men al heal h.
Sus ainabili y 2022,14, 1547 7 o 27
Table 3. Sample gene al cha ac e is ics (n= 1066).
Va iables Ca ego ies n%
Gende Female 573 53.8%
Male 493 46.2%
Age g oup
18–29 172 16.1%
30–44 319 29.9%
45–59 246 23.1%
60–74 202 19.0%
≥75 127 11.9%
Educa ional le el
≤12 yea s 770 72.2%
>12 yea s 296 27.8%
Men al heal h
Good men al heal h
(sco e > 50) 715 67.1%
Poo men al heal h
(sco e ≤50) 351 32.9%
Household Income
≤700 €403 37.8%
701 €–1200 €281 26.4%
1201 €–2000 €229 21.5%
>2000 €153 14.4%
2.4. Me hodology o S a egic Focus on En i onmen al and Men al Heal h Assessmen (SEmHA)
The me hodology o se ing he s a egic ocus and assessmen amewo k wi hin he
SEmHA is based on he me hodological amewo k o “S a egic Thinking o Sus ainabil-
i y” (ST4S) in SEA de eloped by Pa idá io [
27
] and u he elabo a ed by Pa idá io [
115
].
The ST4S me hodological amewo k can be syn hesized in h ee main s ages. The i s
s age is o es ablish he s a egic ocus by conside ing he sus ainabili y con ex wi hin
which he assessmen akes place, and esul s om he c oss-analysis and syn hesis o
p io i y p oblems, policies, and pe cep ions. A s a egic assessmen amewo k is he
ou come o he i s s age and is cen al o ensu ing a s a egic ocus. The amewo k is
de ined by a limi ed numbe o c i ical decision ac o s (CDF) and espec i e assessmen
c i e ia (AC). In ST4S, CDF a e key in eg a ed p io i y hemes ha s uc u e he assessmen
and e alua ion o wha is impo an o assu e he sus ainabili y o in ended s a egies.
CDF a e conside ed success ac o s in a s a egic decision. The second s age in ST4S is he
assessmen o pa hways o sus ainabili y, wi h pa hways ep esen ing al e na i e op ions,
wi h associa ed assessed isks and oppo uni ies in o ming s a egic choices. The CDF
and AC s uc u e he assessmen . Fo each isk and oppo uni y ound, guidelines o
ecommenda ions a e o mula ed. The hi d s age is a con inuous s age, which should un
h oughou he li ecycle o policies, planning, and p og ammes. In his hi d con inuous
s age, moni o ing and pos -e alua ion should be ca ied ou as ollow-up ac i i ies o
any speci ic assessmen , while s akeholde engagemen and p ocess alignmen should be
con inuously done h oughou he policy, planning, and assessmen cycles [115].
Building on he i s s age o his ST4S amewo k (Con ex and s a egic ocus), a
me hodology o de ining he s a egic ocus o en i onmen al condi ions ha enable
men al heal h was de eloped. The pu pose was o de elop he SEmHA amewo k o
p o ide he s uc u e o assess he po en ial impac s ha neighbou hood en i onmen s
may c ea e o he men al heal h o he local popula ion (municipali y le el). The pu pose
o he SEmHA is o p omo e s a egic hinking wi hin he concep s and p inciples o a
HIA [27,115].
The SEmHA amewo k was de eloped in wo phases. Fi s ly, o c ea e a sound
scien i ic baseline o he de elopmen o he me hodology, an assessmen o he neigh-
Sus ainabili y 2022,14, 1547 8 o 27
bou hood en i onmen al e ec s on he men al heal h o he popula ion was conduc ed,
using da a om he su ey applied o he s udy a ea (phase I). Secondly, a me hodology o
ensu e he s a egic ocus in he SEmHA was es ablished, including he iden i ica ion o
CDF and he AC, suppo ed by indica o s, which d aws on he esul s om he su ey—
isk ac o s iden i ied (phase II). The CDF, oge he wi h he AC, ep esen he s a egic
enable s o p omo ing men al heal h. The ollowing sec ion p o ides u he de ails on
he me hodology.
2.4.1. Phase I: Baseline—Unde s anding Neighbou hood En i onmen al Condi ions
The pu pose o his i s phase is o es ablish a sound scien i ic baseline o unde -
s and he neighbou hood en i onmen al condi ions ha may ac as isk ac o s o men al
heal h [27,115], using he da a om he applied su ey.
Se e al binomial logis ic eg ession models we e applied o iden i y he isk ac o s
o poo men al heal h. The dependen a iable o he models was sel -assessed men al
heal h. The neighbou hood en i onmen cha ac e is ics we e modelled indi idually as
independen a iables. Each model was con olled o age and sex. The odds a ios
(ORs) o ha ing poo men al heal h and espec i e 95% con idence in e als (CIs) we e
calcula ed. The binomial logis ic eg ession models we e pe o med using R e sion 3.4.2
(h p://www. -p ojec .o g (accessed on 18 May 2021)) h ough he MGCV package.
This p oduced a baseline o he neighbou hood en i onmen cha ac e is ics ( isk
ac o s) ha a e s a is ically and signi ican ly associa ed wi h men al heal h o in o m he
phase II o he SEmHA.
2.4.2. Phase II: De ini ion o he SEmHA F amewo k
Resul s om phase I we e used o p io i ize co e success ac o s and se he s a e-
gic ocus o he SEmHA. The iden i ica ion o he SEmHA CDF, and i s espec i e as-
sessmen c i e ia and indica o s we e suppo ed by he neighbou hood en i onmen
cha ac e is ics ound in phase I ha p esen ed a high isk o poo men al heal h (odds
a ios ≥1.00
and a
p- alue ≤0.05
). Then, e idence in he scien i ic li e a u e ega ding
he in luence o neighbou hood en i onmen cha ac e is ics on an indi idual’s men al
heal h (e.g.,
[3,13,55,116,117]
) was used o be e unde s and he pa hways o in luence
o he neighbou hood en i onmen ac o s iden i ied, and o s a egically p io i ize and
syn he ise hem in o de o imp o e men al heal h o he communi y a local le el.
3. Resul s
3.1. Baseline—Risks o Poo Men al Heal h
This s udy iden i ied se e al neighbou hood en i onmen al cha ac e is ics ha ep-
esen po en ial isk o poo men al heal h (Figu e 2). The highes signi ican odds a ios
(
≥
2.00; p- alue
≤
0.05) we e ound in he socioeconomic en i onmen . Indi iduals ha e-
po ed di icul y paying expenses, and we e only able o pay cu en expenses, had a signi i-
can ly highe p obabili y o ha ing poo men al heal h han hose ha epo ed he abili y o
sa e money (odds a io o 3.22 and 2.34; 95%CI 2.17–4.78 and 1.74–3.16,
p- alue ≥0.05
, e-
spec i ely). The indi iduals wi h lowe household income (
≤
500
€
) also had a highe signi -
ican isk o ha ing poo men al heal h (odds a io o 2.23;
95%CI 1.60–3.03
,
p- alue ≥0.05
).
In his dimension, o he cha ac e is ics ega ding labou (unemploymen in he amily/ ype
o p o ession) and educa ion also p esen ed isk o men al heal h.
Sus ainabili y 2022,14, 1547 9 o 27
Figu e 2.
Neighbou hood en i onmen cha ac e is ics wi h isk o poo men al heal h: (
a
) physical
and buil en i onmen ; (
b
) socioeconomic en i onmen ; and (
c
) social and cul u al in e ac ion
en i onmen .
Sus ainabili y 2022,14, 1547 16 o 27
hese men al heal h amewo ks, he e is only one, he Communi y De elopmen Key
A eas wi h Impac on Men al Heal h iden i ied by Villeneau e al. [
118
], ha ackles all
he assessmen aspec s iden i ied in his s udy. Howe e , ac oss all he e ised ame-
wo ks, he leas -men ioned ac o is CDF 2. Physical en i onmen quali y, adop ed in his
s udy, which sugges s ha e ec s o he physical neighbou hood en i onmen on men al
heal h condi ions ha e been less-well s udied, and mos ly con ined o epidemiological
s udies
[125,126]
. Ano he dis inc i e ea u e o he p oposed SEmHA amewo k, when
compa ed wi h o he place-o ien ed amewo ks, is i s s a egic ocus and cha ac e o
in o m decision-making on he neighbou hood en i onmen al cha ac e is ics ha need o
be add essed o p omo e he men al heal h o he popula ion a he local le el, and which is
belie ed o be pa icula ly use ul in momen s o c isis [53].
4.2. Discussing Wha Each C i ical Decision Fac o (CDF) En ails
The p oposed holis ic and mul i- ac o SEmHA amewo k highligh s, syn hesizes
and is suppo ed by scien i ic e idence conce ning he join e ec s o u ban cha ac e is ics
a he local le el, as shown by he esul s ound in he Lisbon Region s udy a ea.
4.2.1. CDF 1. Public Space Quali y
Rega ding CDF 1. ( he highe isks o men al heal h o no being sa is ied wi h he
sa e y o he esidence a ea, lowe amily and communi y ela ional suppo , sense o
belonging and iden i y, and us in public ins i u ions), li e a u e suppo s he impo ance
and capaci y o public space o con ibu e o he men al heal h gains o he popula ion.
Adequa e s ee ligh ing and u ban u ni u e loca ion (e.g., communal sea ing), clean and
main ained spaces (e.g., wi hou accumula ed ash), he p esence o na u e, public a ,
he i age/pa imonial and iden i y elemen s, and he exis ence o undeg aded buildings
wi hou signs o andalism, a e all ea u es ha can ha e posi i e e ec s on men al heal h
and educe he ea o c ime [
65
,
127
–
130
], inju ies [
131
], and he pe cep ion o unsa e
neighbou hoods [
132
]. Se e al s udies also sugges ha an en i onmen ha enables
walking sa e y can imp o e he men al heal h o he popula ion by inc easing he p ac ice
o physical ac i i y o di e en age g oups [
133
–
138
]. This is pa icula ly ele an in na u al
se ings when compa ed o indoo se ings [
139
,
140
]. The aes he ics o , access (p oximi y) o,
and engagemen wi h public spaces, namely g een and blue spaces, a e ele an assessmen
dimensions o he p omo ion o social in e ac ion and ac i e li ing [128,141–145].
Conce ning public space in e en ions, go e nmen s can adop s a egies a he local
le el o de elop men al heal h- iendly neighbou hood en i onmen s, based on he design
and on he managemen o public space. These mus be sa e, accessible, aes he ically
pleasing, cul u ally app op ia e, and allow con ac wi h na u e, as well as com o able
pedes ian ac i i y [
14
,
146
,
147
]. Fo ins ance, he p esence o sidewalks, places o si ,
playg ounds, sa e well-li c osswalks, building accessibili y (e.g., com o able common
en ances), dedica ed o channelized a ic mo emen s and adjus ed ehicle speeds, can
inc ease he sa e y and usabili y o public space, and in luence indi idual choices ega ding
heal hy li es yles (e.g., ea ing habi s, physical ac i i y, social connec ions) [
146
]. In addi ion,
he nega i e impac s o isola ion and loneliness on men al heal h can be mi iga ed by
p omo ing neighbou hood wa ch (c ime p e en ion awa eness) and neighbou hood walka-
bili y, as well as enabling esiden s o nu u e posi i e local ela ionships and ake pa in
communi y li e [
146
,
148
]. This inc eases he sense o place o neighbou hoods h ough he
ein o cemen o iden i y and belonging [
143
,
149
]. Many aspec s o social engagemen can
be s eng hened h ough he in ol emen o esiden s in planning p ocesses, such as: bonds
and ne wo ks be ween neighbou s; communi y cohesion; he pe cep ion o neighbou hood
secu i y; p oximi y o iends and amily; and he sense o empowe men , connec ion, and
communi y esponsibili y. [118,143,146,149,150].

Sus ainabili y 2022,14, 1547 17 o 27
4.2.2. CDF 2. Physical En i onmen Quali y
Conce ning CDF 2, esul s om he s udy ein o ce he idea ha he quali y o he
physical (na u al) en i onmen , namely access o clean ai [
125
,
151
], low le els o noise
exposu e [
133
,
137
], and u ban cleanliness [
152
–
154
], is associa ed wi h be e men al heal h
ou comes. Mo eo e , neighbou hoods wi h low pollu ion le els also encou age he p ac ice
o ou doo physical ac i i y and o ac i e anspo , wi h associa ed bene i s o men al
heal h [
134
,
155
]. The posi i e impac s on men al heal h o imp o ing he quali y o he
physical en i onmen can be assis ed by local neighbou hood planning p ocesses [
146
],
h ough a ange o in e en ions, o ins ance dec easing public space decay, ash build-
up, and andalism using unc ional and p oximi y solid was e managemen and u ban
cleaning se ices. U ban ai pollu ion (g eenhouse gas, ca bon monoxide, hyd oca bons,
oxides o ni ogen, g ound le el ozone, and pa icula e ma e ), can be educed by adop ing
na u e-based solu ions, expanding na u al elemen s ac oss u ban landscapes (e.g., ees,
g eenways, u ban ag icul u e, g een pa ks), lowe ing ehicle speed limi s, loca ing es-
iden ial a eas a a sa e dis ance om ehicle exhaus s, and main aining sho walking
dis ances (ac i e anspo a ion/mobili y) be ween homes and se ices/ acili ies. Noise
exposu e and pollu ion, pa icula ly he e ec s o indoo noise, can be educed h ough
housing loca ion c i e ia such as he p oximi y o noise emission sou ces, o ins ance
busy oadways (e.g., highways), ailways (e.g., s a ions) and ai po s (e.g., ake-o and
landing ou es and ai a ic holding a eas), and p omo ing be e quali y cons uc ion and
enewal o buildings, such as incen i es o he ins alla ion o e icien insula ion sys ems
(e.g., double glazing).
4.2.3. CDF 3. P o essional Quali ica ion and C ea ion o Economic Ac i i ies
Wi h espec o CDF 3, he isks o men al heal h ela e o household inancial di -
icul ies due o low household income, unemploymen , unquali ied wo k, and low ed-
uca ion le els. Resul s show he e is a clea and well-known connec ion be ween men-
al ill-heal h and low income and po e y, low educa ional s a us, and also unemploy-
men [
51
,
116
,
120
,
156
]. Fu he mo e, he men al heal h o he communi y is also a ec ed by
eelings o insecu i y and he loss o con ol ela ed wi h he combined e ec o indi idual
social isola ion and disin eg a ion [120].
In his con ex , he AC 3.1 p o essional quali ica ion assessmen c i e ion highligh s
he impo an ole played by local go e nmen s in suppo ing con inuous educa ion and
li elong lea ning p og ammes capable o esponding o neighbou hood and communi y
needs and esul ing in posi i e consequences o men al heal h [
157
,
158
]. Educa ion is
a c ucial dimension in enabling dep i ed g oups o expand capabili y, mi iga e psycho-
logical dis ess, and de elop sel -es eem [
120
,
159
]. I is especially impo an o de elop
quali ica ion s a egies and ac i i ies h oughou li e, in di ec pa ne ship wi h schools
and en e p ises, ela ed o oca ional and suppo ed aining ha enhances and imp o es
wo king capaci y, coping skills, and labou ma ke compe ences (e.g., o unquali ied wo k-
e s) [
120
,
157
]. These educa ion p og ammes can also help in he p omo ion o in e pe sonal
awa eness and he main enance o social con ac s [149].
The AC 3.2 new economic ac i i ies and business ini ia i es, and 3.3 employmen
and labou , emphasize he capaci y o a ac and suppo economic dynamics and weal h
gene a ion a he local le el, which can b ing employmen oppo uni ies ha in eg a e
indi iduals ou side he labou ma ke , as well as p omo ing sus ainable wo k and inancial
independence [
149
]. The e is scien i ic suppo sugges ing ha local go e nmen s can
omen and c ea e condi ions o hos and s eng hen new business ini ia i es and o ms
o wo k h ough o ganiza ions ha build up and acili a e s uc u e, compe ences, ne -
wo ks and pa ne ships [
160
,
161
], o ins ance, incuba o s, s a -ups, olun a y wo k, and
co-ope a i es. Con ibu ing o ac i e job c ea ion should be used o p e en local unem-
ploymen , pa icula ly long- e m unemploymen , and p o ide, o example, condi ions o
en ep eneu ship [120,160,162].
Sus ainabili y 2022,14, 1547 18 o 27
4.2.4. CDF 4. Se ices and Facili ies
Rega ding CDF 4, ou indings show ha he isk o men al heal h ela es o he quali y
and a ailabili y o se e al se ices and acili ies in he esiden ial a ea. Se e al s udies
poin ou he impo ance o p o ision and access o local se ices and acili ies, and hei
walking p oximi y, o be e men al heal h and wellbeing o he popula ion [
163
–
165
]. A
he local le el, mixed land use de elopmen s (p oximi y o se ices and acili ies o housing
op ions) ha p io i ize access o, o ins ance, heal h ca e, schools, spo and ec ea ional
cen es, social and communi y ameni ies and g oce y s o es, can inc ease walking and
cycling [
166
,
167
] and consequen ly he le el o physical ac i i y o he popula ion [
148
],
wi h associa ed posi i e impac s on men al heal h. The place in es men in neighbou hood
walking connec i i y and easy access o se ices and acili ies can impac posi i ely on
he neighbou hood’s men al heal h h ough changes in mobili y habi s (p io i ising ac i e
and public anspo a ion o e indi idual o ms) and he inc ease o social capi al and
communi y engagemen [
128
,
142
,
168
–
172
]. These changes can consequen ly imp o e
neighbou hood us and also expand people’s in ol emen and pa icipa ion in local
decision-making p ocesses [146].
4.3. Discussing he Use ulness and Applicabili y o he S a egic Focus on En i onmen al and
Men al Heal h Assessmen (SEmHA) F amewo k
O e all, he esul s e eal ha his s a egic ocus and assessmen amewo k, wi h
he a o emen ioned CDF and AC, i used o assess local planning s a egic op ions, is
likely o suppo local decision-making in c ea ing local condi ions ha a ou men al
heal h. Each case has i s own singula i ies, so wha is ele an in he Lisbon Region
(Po ugal) may no apply exac ly in he same way o o he places. Howe e , wi h espec
o he Lisbon Region, i appea s ha p omo ing compac ed, connec ed, inclusi e, and
na u al u ban neighbou hoods in which people can mo e ia ac i e o so anspo a ion,
access se ices, as well as aes he ic ec ea ional and g een spaces, and also eel sa e and
com o able o pa icipa e in communi y li e [
14
,
146
,
173
], will likely c ea e be e condi ions
o men al heal h. As men ioned abo e, he li e a u e has demons a ed he associa ion
be ween popula ion/ esiden ial densi y and men al heal h and wellbeing (e.g., le els o
disease, us , ole ance, pa icipa ion) [
174
–
177
]. Howe e , e idence also shows ha
mo e esea ch is needed o be e unde s and he le els o popula ion/ esiden ial/se ices
densi y bene icial o men al heal h [177].
This s udy suppo s he impo ance o adop ing s a egic hinking in en i onmen al
and heal h assessmen s o ensu e ha commi men o men al heal h p omo ion is embedded
in u ban local policies ac oss all sec o s. A Men al Heal h in All Policies conside s he
sys emic and complex ela ionships ha ake place wi hin neighbou hoods and hei e ec s
a he local le el [
41
,
42
,
149
]. Knowledge and assessmen o he men al heal h needs o he
popula ion, pa icula ly hose who a e ulne able, disad an aged, o a isk, a e c ucial
o imp o ing heal h equi y and o suppo ing poli ical decision-making ha ensu es
ha e e yone has li elong access o he same condi ions, se ices and ameni ies o he
neighbou hood. [149,178].
Du ing pe iods o c isis, such as he cu en COVID-19 pandemic, he nega i e im-
pac s on men al heal h a e a eali y (e.g., inc eases in dep ession, anxie y, alcohol and
subs ance misuse, an idep essan usage, iolence, emo ional dis ess, poo quali y o li e,
and educed wellbeing), as a esul o , o ins ance, ea o in ec ion and dea h, loss o
lo ed ones, social dis ancing and educed in e ac ion, income insecu i ies, local labou
ma ke decline, aus e i y measu es, and d as ic changes in daily ou ines [
9
,
52
,
179
–
181
].
These consequences, oge he wi h he inc ease in heal h inequali ies, usually wo sen he
condi ions o he ulne able and excluded [
10
,
11
,
52
,
182
]. This s a egic and assessmen
amewo k can help o suppo and s uc u e he in e en ions in men al heal h a he local
le el, helping o mi iga e he ex en and in ensi y o immedia e and long- e m nega i e
e ec s [
29
,
183
–
185
]. Heal h Impac Assessmen me hodologies ha e been e ealed as a
Sus ainabili y 2022,14, 1547 19 o 27
bene icial ool o in o m and unde s and policy decisions and unp edic ed majo e en s
such as he COVID-19 pandemic [53].
4.4. S eng hs, Limi a ions and Fu u e Resea ch
The p oposed me hodology o es ablish a s a egic ocus and espec i e assessmen
amewo k comes wi h s eng hs and limi a ions.
In e ms o s eng hs, i illus a es a possible ou line o a s uc u ed amewo k o
applying a s a egic ocus in a HIA a he local le el, buil upon he pe cep ions o he
esiden popula ion o ou municipali ies in he Lisbon Region. I s applica ion and adap-
a ion o o he le els, scales, and con ex s could be bene icial, pa icula ly in he public
sec o s, o unde s anding how policies can a ec he onse o men al diso de s as well
as he imp o emen o popula ion men al heal h and heal h equi y. The assessmen e-
sul s also help iden i y oppo uni ies o in e sec o al and collabo a i e ac ion ha could
imp o e neighbou hood en i onmen s and consequen ly p omo e he men al heal h o
he popula ion. We belie e his is he i s s udy in ol ing a SEA-based app oach ha
ga he s and ela es neighbou hood en i onmen cha ac e is ics and men al heal h. This
amewo k allows: (i) assessing he enabling condi ions o men al heal h h ough each CDF,
(ii) iden i ying poin s o s a egic public in e en ion, (iii) moni o ing changes o e ime
o he design o e alua ion o p og ammes and policies, (i ) suppo ing he concep ion
o e idence-based in e en ions ha ha e a highe p obabili y o long- e m impac on
men al heal h.
The s udy’s design and me hodology con ain limi a ions wi h espec o he sel -
epo ed indi idual da a om pe cep ions o he neighbou hood and men al heal h s a us,
which may no co espond o an exac eali y, and can be in luenced by memo y bias
o social desi abili y [
186
]. The CDF, AC, and indica o s we e de eloped h ough he
su ey ins umen and dialogue/discussion wi h municipali y mayo s and pa ish council
p esiden s. This was limi ed due o ime and cos cons ain s, whe eas u he combined
quali a i e app oaches a e ecommended wi h he pa icipa ion o di e en communi y
s akeholde s [
187
,
188
]. In de eloping he CDF and AC, s a is ical associa ions be ween
neighbou hood cha ac e is ics and men al heal h ou comes we e used, bu his should
no be in e p e ed as i he e is a di ec causali y, as some indi ec causes may jus i y he
ela ionship [
189
]. Ano he limi a ion o he s udy was he use o indica o s ha a e ela ed
o he Po uguese con ex and which a ailabili y o da a a he local le el may be limi ed.
Applica ion o he s a egic ocus and assessmen amewo k o a local le el s udy a ea
(e.g., neighbou hood, municipali y, o a se o municipali ies) would be he nex s ep o
u u e esea ch. This would p o ide an unde s anding o he ope abili y o he amewo k
in iden i ying and assessing s a egic planning op ions ha could in o m local plans and
policies and mo e adequa ely imp o e men al heal h.
5. Conclusions
The s udy p oposed a s a egic ocus and assessmen amewo k—SEmHA—applied
o he neighbou hood en i onmen al condi ions o he s udy a ea ( ou municipali ies in
he Lisbon Region ollowing a pe iod o economic c isis), enabling assessmen o men al
heal h a he local le el, by combining holis ic, and in e sec o al app oaches.
The c i ical decision ac o s iden i ied o s a egically ac on communi y men al heal h
we e (i) public space quali y, (ii) physical en i onmen quali y, (iii) p o essional quali ica ion
and c ea ion o economic ac i i ies, and (i ) se ices and acili ies. These esul s sugges
ha an inc ease in men al heal h bene i s can be os e ed h ough he neighbou hood
en i onmen , landscape and communi y planning, and design in e en ions, aking in o
accoun land use suppo decisions ha can, o ins ance, compac u ban neighbou hoods,
inc ease he mix o land uses and, in some a eas, u ban densi y. The p oposed s a egic
ocus and assessmen amewo k con ibu es o ensu ing ha he neighbou hood en i-
onmen in e en ions uly achie e communi y imp o emen s and educe inequali ies,
Sus ainabili y 2022,14, 1547 20 o 27
h ough cyclical assessmen and moni o ing o he impac s on well-being, heal h, and
heal h equi y [190].
Using he p oposed SEmHA amewo k o gua an ee a s a egic ocus on he assess-
men o neighbou hood en i onmen al impac s on men al heal h a he local le el will
help policy make s o iden i y and assess s a egic op ions ha enable he c ea ion (and
econ e sion) o mo e comple e, mo e sus ainable and mo e li eable neighbou hood en i-
onmen s, whe e indi iduals can enjoy hei men al heal h choices, hus imp o ing place
and communi y esilience du ing imes o c isis.
Au ho Con ibu ions:
Concep ualiza ion, A.L., M.d.R.P. and P.S.; da a cu a ion, A.L.; o mal anal-
ysis, A.L.; unding acquisi ion, P.S.; in es iga ion, A.L.; me hodology, A.L. and M.d.R.P.; p ojec
adminis a ion, P.S.; esou ces, A.L.; so wa e, A.L.; supe ision, M.d.R.P. and P.S.; alida ion, A.L.;
w i ing—o iginal d a , A.L.; w i ing— e iew and edi ing, A.L., M.d.R.P., and P.S. All au ho s ha e
ead and ag eed o he published e sion o he manusc ip .
Funding:
This esea ch was unded by he in es iga ion p ojec PTDC/ATP-GEO/4101/2012,
SMAILE, Men al Heal h—E alua ion o he Local and Economic De e minan s, unded by he
Po uguese Founda ion o Science and Technology (FCT) and he Eu opean Regional De elop-
men Fund (FEDER), h ough he COMPETE—Ope a ional Compe i i eness P og am. Ad iana
Lou ei o is unded by FCT doc o al ellowship SFRH/BD/92369/2013 and by he CEGOT (Cen e
o S udies in Geog aphy and Spa ial Planning) en i led “Ci ies, compe i i eness, and well-being”
(UID/GEO/04084/2013) h ough COMPETE 2020. Ad iana Lou ei o and Paula San ana ecei ed
suppo om he Cen e o S udies in Geog aphy and Spa ial Planning (CEGOT), unded by na ional
unds h ough he FCT unde he e e ence UIDB/04084/2020.
Ins i u ional Re iew Boa d S a emen :
The s udy was conduc ed in acco dance wi h he Decla a ion
o Helsinki, and app o ed by he Resea ch E hics Commi ee o Cen o Hospi ala Lisboa Ociden al
(Hospi al o Me opoli an A ea o Lisbon, Po ugal) (28 No embe 2013), ha p o ided e hics
app o al o his s udy, in eg a ed in he esea ch p ojec SMAILE, Men al Heal h—E alua ion o he
Local and Economic De e minan s.
In o med Consen S a emen :
In o med consen was ob ained om all subjec s in ol ed in he s udy.
Acknowledgmen s:
The au ho s hank he commen s om Ângela F ei as, Rica do Almend a and
Cláudia Cos a (CEGOT-UC), Ma ga ida Mon ei o and Ru e Ma ins (IST-UL) and Manuela Sil a
(CEDOC-NMS) ha con ibu ed o imp o e he design o he manusc ip . The au ho s also hank
he in es iga o s (Ca la Nunes, G aça Ca doso, JoséCaldas de Almeida and Ped o Pi a Ba os) and
consul an s (Benede o Sa aceno and João Fe ão) o he SMAILE P ojec . In addi ion, he au ho s
hank Linda Naugh on o he english e iew and he h ee e iewe s o he manusc ip o hei
commen s, ecommenda ions and sugges ions o imp o emen .
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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